Incidentaloma physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Most of patients will not show any special signs as the definition of adrenal incidentaloma means incidentaly discovered mass during imaging for ant other reasons. Some cases show signs of subclinical Cushing’s syndrome, pheochromocytoma, or hyperaldosteronism. Common physical examination findings of include patients may appear quite well if the disease is asymptomatic. Patients may appear tired, weak, diaphoretic and anxious. Tachypnea if malignant secondaries are found in the lung with a rapid strong equal pulse and high blood pressure. Jaundice, hyperpigmentation, Telangiectasia, thinning of the skin and easy bruising may be found. A palpable abdominal mass in the lower abdominal quadrant may be found. Hyporeflexia due to low potassium level in aldosternonma, Proximal muscle weakness bilaterally, and bilateral tremors may be found.

Physical examination of incidentaloma is dependent on the underlying cause and the nature of the lesion in the adrenal glands. Some cases may show signs of subclinical Cushing’s syndrome, pheochromocytoma, or hyperaldosteronism.

Physical examination of patients with subclinical Cushing’s syndrome is as follows:^[1]

• Patients with Cushing’s syndrome usually appears overweight.

• Hypertension, due to cortisol’s enhancement of epinephrine‘s vasoconstrictive effect.

• Moon-face is a medical sign where the face swells up into a rounded shape. It is often associated with Cushing’s syndrome, which has led to it being known as Cushingoid facies (“Cushings-like face”), or steroid treatment, which has led to the name steroid facies.

• Hyperpigmentation – this is due to melanocyte-stimulating hormone production as a byproduct of ACTH synthesis from Proopiomelanocortin (POMC)
• Telangiectasia (dilation of capillaries)
• Thinning of the skin (which causes easy bruising)
• Purple or red striae (the weight gain in Cushing’s stretches the skin, which is thin and weakened, causing it to hemorrhage) on the trunk, buttocks, arms, legs or breasts, proximal muscle weakness (hips, shoulders)
• Hirsutism (facial male-pattern hair growth)

• Bitemporal hemianopsia – pituitary lesion may compress the optic chiasm

• Growth of fat pads along the collar bone and on the back of the neck (known as a lipodystrophy)

• Patients may appear tired, weak, diaphoretic and anxious.^[2]
• Patients may appear quite well if the disease is asymptomatic.
• Patients may appear flushed due to associated increase in erythropoietin secretion.^[3]
• Patients may appear obese due to associated type2 diabetes mellitus and Cushing’s syndrome.^[4]

• Tachycardia with a regular pulse. Irregular pulse may occurr in supraventricular tachycardia.
• Tachypnea if malignant secondaries are found in the lung. Dyspnea occurs in patients with complicated heart failure and cardiomyopathy.
• Rapid strong equal pulse.
• High blood pressure with normal pulse pressure.
• Hypotension occurs due to fluid contraction.

• Jaundice secondary to deranged liver function in case of metastasis to the liver.

• Facial flushing.
• Scleral icterus in case of metastasis to the liver.
• MEN2 patients associated with mucosal neuromas show multiple lips and tongue neuromas.

• Congested neck veins in patients with cardiomyopathy.^[5]

• Painless lymphadenopathy if malignant secondaries found in the neck (rapid increase in the size of the node. Prevalence of malignancy in lymph node biopsies performed is 60%.^[6]
• Thyromegaly/thyroid nodules if MEN patients due to medullary thyroid cancer.^[7]

• Asymmetric chest expansion / decreased chest expansion if malignant secondaries are found in the lung.

• Chest tenderness upon palpation in MEN1 patients due to hyperparathyroidism.
• Palpation: Precordial heave especially at apex due to left ventricular hypertrophy in long standing patients.
• Auscultation: normal S1 and accentuated S2 due to high systemic resistance.

• Abdominal distention in patients with primary hyperparathyroidism associated constipation or Hirschsprung disease.
• Abdominal tenderness in the lower abdominal quadrants in MEN2 patients with Hirschsprung disease.^[8]
• A palpable abdominal mass in the lower abdominal quadrant.
• Guarding may be present.
• Hepatomegaly if malignant secondaries found in liver.
• Diarrhea caused by gastrointestinal secretion of fluid and electrolytes, and flushing in medullary thyroid cancer patients.^[9]

• Point tenderness in MEN1 patients with hyperparathyroidism.

• Patient is usually well-appearing

• Normal body temperature
• Tachycardia with irregular pulse^[10][11]
• Normal respiratory rate
• High blood pressure may be the only presenting sign

• There are no abnormal skin findings associated with primary hyperaldosteronism

• HEENT examination is normal in primary hyperaldosteronism.

• No lymphadenopathy
• No thyromegaly

• Elevated JVP

• Symmetric chest expansion
• Normal breath sounds
• No rales, rhochi and wheeze
• Egophony absent
• Bronchophony absent
• Normal tactile fremitus

• No chest tenderness on palpation
• PMI within 2 cm of the sternum
• S1
• S2
• S4 may be heard due to left ventricular hypertrophy^[12]
• No gallop rhythm
• Ventricular fibrillation may be a finding in primary hyperaldosteronism^[13]

• Non-tender
• Non-distended
• No abnormal fluids or gas
• No palpable organomegaly

• There are no abnormal findings on the back associated with primary hyperaldosteronism.

• There are no abnormal genitourinary findings associated with primary hyperaldosteronism

• Extremities are normal on examination in primary hyperaldosteronism

• Hyperaldosteronism induced hypertension may lead to stroke and paralysis^[14]

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